ELECTROCONVULSIVE THERAPY

Introduction

Electroconvulsive therapy (ECT), also known as electroshock, is a well-

established, albeit controversial, psychiatric treatment in which seizures are electrically
induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as
a treatment for severe major depression which has not responded to other treatment, and
is also used in the treatment of mania (often in bipolar disorder), and catatonia.[1] It was
first introduced in the 1930s and gained widespread use as a form of treatment in the
1940s and 1950s; today, an estimated 1 million people worldwide receive ECT every
year, usually in a course of 6–12 treatments administered 2 or 3 times a week.

Electroconvulsive therapy can differ in its application in three ways: electrode

placement, length of time that the stimulus is given, and the property of the stimulus. The
variance of these three forms of application have significant differences in both adverse
side effects and positive outcomes. After treatment, drug therapy can be continued, and
some patients receive continuation/maintenance ECT. Informed consent is a standard of
modern electroconvulsive therapy. Involuntary treatment is uncommon in countries that
follow contemporary standards and is typically only used when the use of ECT is
believed to be potentially life saving.

Meaning and Definition

Electroconvulsive therapy or ECT for short is a controversial treatment in

which a convulsion or seizure is produced by passing an electric current through the
brain. ECT is primarily used for treatment-resistant depression and may also be
prescribed for mania and schizophrenia. Given under anesthesia, ECT may be unilateral
(electrodes on one side of the head) or bilateral (electrodes on both sides). The most
common side effect of electroconvulsive therapy is memory loss.

History

As early as the 16th century, agents to produce seizures were used to treat
psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented
in the London Medical Journal. Convulsive therapy was introduced in 1934 by Hungarian
neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and
epilepsy were antagonistic disorders, induced seizures with first camphor and then
metrazol (cardiazol). Within three years metrazol convulsive therapy was being used
worldwide. In 1937, the first international meeting on convulsive therapy was held in
Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the
American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was
being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti, who had been
using electric shocks to produce seizures in animal experiments, and his colleague Lucio
Bini developed the idea of using electricity as a substitute for metrazol in convulsive
therapy and, in 1937, experimented for the first time on a person. Sherwin B. Nuland
having discussed the matter with a first-hand observer in the 1970s gave the following
description of the results of the first use of ECT on a person:

"They thought, 'Well, we'll try 55 volts, two-tenths of a second. That's not going
to do anything terrible to him.' So they did that. [...] This fellow — remember, he
wasn't even put to sleep — after this major grand mal convulsion, sat right up,
looked at these three fellows and said, 'What the fuck are you assholes trying to
do?' Well, they were happy as could be, because he hadn't said a rational word in
the weeks of observation."

ECT soon replaced metrazol therapy all over the world because it was cheaper,
less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize
but did not receive one. By 1940, the procedure was introduced to both England and the
US. Through the 40's and 50's the use of ECT became widespread. ECT is the only form
of shock treatment still performed by modern medicine.

In the early 1940s, in an attempt to reduce the memory disturbance and confusion
associated with treatment, two modifications were introduced: the use of unilateral
electrode placement and the replacement of sinusoidal current with brief pulse. It took
many years for brief-pulse equipment to be widely adopted[101] Unilateral ECT has never
been popular with psychiatrists and is still only given to a minority of ECT patients. In
the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle
relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious
complication of unmodified ECT was fracture or dislocation of the long bones. In the
1940s psychiatrists began to experiment with curare, the muscle-paralyzing South
American poison, in order to modify the convulsions. The introduction of
suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to
the more widespread use of "modified" ECT. A short-acting anesthetic was usually given
in addition to the muscle relaxant in order to spare patients the terrifying feeling of
suffocation that can be experienced with muscle relaxants.[101]

The steady growth of antidepressant use along with negative depictions of ECT in
the mass media led to a marked decline in the use of ECT during the 50's to the 70's. The
Surgeon General stated there were problems with electroshock therapy in the initial years
before anesthesia was routinely given and, these now antiquated practices contributed to
the negative portrayal of ECT in the popular media. The New York Times described the
public's negative perception of ECT as being caused mainly by one movie, "For Big
Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and in the public mind
shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous,
inhumane and overused".

In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current,

brief pulse device ECT. This device eventually largely replaced earlier devices because
of the reduction in cognitive side effects, although some ECT clinics in the US still use
sine-wave devices. The 1970s saw the publication of the first American Psychiatric
Association task force report on electroconvulsive therapy (to be followed by further
reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of
depression. The decade also saw criticism of ECT. Specifically critics pointed to
shortcomings such as noted side effects, the procedure being used as a form of abuse, and
uneven application of ECT. The use of ECT declined until the 1980s, "when use began to
increase amid growing awareness of its benefits and cost-effectiveness for treating severe
depression". In 1985 the National Institute of Mental Health and National Institutes of
Health convened a consensus development conference on ECT and concluded that, whilst
ECT was the most controversial treatment in psychiatry and had significant side-effects,
it had been shown to be effective for a narrow range of severe psychiatric disorders.

Due to the backlash noted previously, national institutions reviewed past practices
and set new standards. In 1978, The American Psychiatric Association released its first
task force report in which new standards for consent were introduced and the use of
unilateral electrode placement was recommended. The 1985 NIMH Consensus
Conference confirmed the therapeutic role of ECT in certain circumstances. The
American Psychiatric Association released its second task force report in 1990 where
specific details on the delivery, education, and training of ECT were documented. Finally
in 2001 the American Psychiatric Association released its latest task force report. This
report emphasizes the importance of informed consent, and the expanded role that the
procedure has in modern medicine.

Indications

There is considerable variability in opinion among experts as to whether ECT is

appropriate as a first-line treatment or if its use should be reserved for patients who have
not responded to other interventions such as medication and psychotherapy.

The American Psychiatric Association (APA) 2001 guidelines give the primary
indications for ECT among patients with depression as a lack of a response to, or
intolerance of, antidepressant medications; a good response to previous ECT; and the
need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide).
The decision to use ECT depends on several factors, including the severity and chronicity
of the depression, the likelihood that alternative treatments would be effective, the
patient's preference, and a weighing of the risks and benefits.

Some guidelines recommend that cognitive behavioral therapy or other

psychotherapy should generally be tried before ECT is used. However, treatment
resistance is widely defined as lack of therapeutic response to two antidepressants. The
APA states that at times patients will prefer to receive ECT over alternative treatments,
but commonly the opposite will be the case.

The APA ECT guidelines state that severe major depression with psychotic
features, manic delirium, or catatonia are conditions for which there is a clear consensus
favoring early reliance on ECT. The NICE guidelines recommend ECT for patients with
severe depression, catatonia, or prolonged or severe mania.
 The 2001 APA guidelines support the use of ECT for relapse prevention, but the
2003 NICE guidelines do not.

The 2001 APA ECT guidelines say that ECT is rarely used as a first-line
treatment for schizophrenia but is considered after unsuccessful treatment with
antipsychotic medication, and may also be considered in the treatment of patients with
schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not
recommend ECT for schizophrenia.

The NICE 2003 guidelines state that doctors should be particularly cautious when
considering ECT treatment for women who are pregnant and for older or younger people,
because they may be at higher risk of complications with ECT. The 2001 APA ECT
guidelines say that ECT may be safer than alternative treatments in the infirm elderly and
during pregnancy, and the 2000 APA depression guidelines stated that the literature
supports the safety for mother and fetus, as well as the efficacy during pregnancy.

Procedure

ECT is usually given 3 times a week. A patient may require as few as 3 or 4

treatments or as many as 12 to 15. Once the family & patient consider that the patient is
more or less back to his normal level of functioning, it is usual for the patient to have 1 or
2 additional treatments in order to prevent relapse. Today the method is painless, & with
modifications in technique it bears little relationship to the unmodified treatments of the
1940s.

The patient is put to sleep with a very short-acting barbiturate, & then the drug
succinycholine is administered to temporarily paralyze the muscles so they do not
contract during the treatment & cause fractures. An electrode is placed above the temple
of the nondominant side of the brain, & a second in the middle of the forehead (this is
called unilateral ECT); or one electrode is placed above each temple (this is called
bilateral ECT). A very small current is passed through the brain, activating it &
producing a seizure. Because the patient is anesthetized & his body is totally relaxed by
the succinycholine, he sleeps peacefully while an electroencephalogram (EEG) monitors
the seizure activity & an electrocardiogram (EKG) monitors the heart rhythm. The
current is applied for one second or less, & the patient breathes pure oxygen through a
mask. The duration of a clinically effective seizure ranges from 30 seconds to sometimes
longer than a minute, & the patient wakes up 10 to 15 minutes later. Upon awakening, a
patient may experience a brief period of confusion, headache or muscle stiffness, but
these symptoms typically ease in a matter of 20 to 60 minutes. During the few seconds
following the ECT stimulus there may be temporary drop in blood pressure. This may be
followed by a marked increase in heart rate, which may then lead to a rise in blood
pressure. Heart rhythm disturbances, not unusual during the period of time, generally
subside without complications. A patient with a history of high blood pressure or other
cardiovascular problems should have a cardiology consultation first.
Because as many as 20 to 50 percent of the people who respond well to a course of ECT
relapse within 6 months, a maintenance treatment of antidepressants, lithium or ECT at
monthly or 6 week intervals might be advisable.
Short-term memory loss has always been a concern to patients who receive ECT,
but several studies conclude that patients who received unilateral ECT performed better
on attention/memory tests than those who received bilateral ECT. However, there is a
question as to whether unilateral is as effective. Experts agree that changes in memory
function do occur & persist for a few days following treatment, but that patients return to
normal within a month. A 1985 NIMH Consensus Conference concluded that while some
memory loss is frequent after ECT, it is estimated that one-half of 1 percent of ECT
patients suffer severe loss. Memory problems usually clear within 7 months of treatment,
although there may be a persistent memory deficit for the period immediately
surrounding the treatment.

Non-clinical patient characteristics

About 70 percent of ECT patients are women. This is largely, but not entirely, due
to the fact that women are more likely to receive treatment for depression. Older and
more affluent patients are also more likely to receive ECT. The use of ECT treatment is
"markedly reduced for ethnic minorities."

Effectiveness

The 1999 U.S. Surgeon General's Report on Mental Health summarized

psychiatric opinion at the time about the effectiveness of ECT. It stated that both clinical
experience and published studies had determined ECT to be effective (with an average 60
to 70 percent remission rate) in the treatment of severe depression, some acute psychotic
states, and mania. Its effectiveness had not been demonstrated in dysthymia, substance
abuse, anxiety, or personality disorder. The report stated that ECT does not have a long-
term protective effect against suicide and should be regarded as a short-term treatment for
an acute episode of illness, to be followed by continuation therapy in the form of drug
treatment or further ECT at weekly to monthly intervals. A 2004 large multicentre
clinical follow-up study of ECT patients in New York—describing itself as the first
systematic documentation of the effectiveness of ECT in community practice in the 65
years of its use—found remission rates of only 30 to 47 percent, with 64 percent of those
relapsing within six months.

ECT on its own does not usually have a sustained benefit. Virtually all those who
remit end up relapsing within six months following a course, even when given a placebo.
The relapse rate in the first six months may be reduced by the use of psychiatric
medications or further ECT, but remains high.

Most, but not all, published reviews of the literature have concluded that ECT is
effective in the treatment of depression. In 2006, research psychiatrist Colin A. Ross
reviewed the entire body of placebo-controlled literature on ECT and found that no study
showed a significant difference between real and placebo ECT at one month post-
treatment. The review also found that many of these studies failed to find a difference
between real and placebo ECT even during the period of treatment. Based on these
observations, Dr. Ross concludes that "claims in textbooks and review articles that ECT
is effective are not consistent with the published data", and that consent forms for the
procedure should state that "real ECT is only marginally more effective than placebo."
The review was highly critical of other published reviews concluding that ECT was
effective, because these reviews often relied primarily on studies that were not placebo-
controlled.

Adverse effects

Aside from effects in the brain, the general physical risks of ECT are similar to
those of brief general anesthesia; the United States' Surgeon General's report says that
there are "no absolute health contraindications" to its use. Immediately following
treatment the most common adverse effects are confusion and memory loss. The state of
confusion usually disappears after a few hours. Some patients experience muscle soreness
after ECT. This is due to either the muscle relaxants given during the procedure or due to
the muscle activity caused by the seizure.

Effects on memory

It is the effects of ECT on long-term memory that give rise to much of the
concern surrounding its use. The acute effects of ECT can include amnesia, both
retrograde (for events occurring before the treatment) and anterograde (for events
occurring after the treatment). Memory loss and confusion are more pronounced with
bilateral electrode placement rather than unilateral, and with sine-wave rather than brief-
pulse currents. The vast majority of modern treatment uses brief pulse currents. Research
by Harold Sackeim has shown that excessive current causes more risk for memory loss,
and shocking only the right side of the head protects the left side, which contains the
brain's verbal structure.

Retrograde amnesia is most marked for events occurring in the weeks or months
before treatment, with one study showing that although some people lose memories from
years prior to treatment, recovery of such memories was "virtually complete" by seven
months post-treatment, with the only enduring loss being memories in the weeks and
months prior to the treatment. Anterograde memory loss is usually limited to the time of
treatment itself or shortly afterwards. In the weeks and months following ECT these
memory problems gradually improve, but some people have persistent losses, especially
with bilateral ECT. One published review summarized the results of seven studies
reporting on perceived memory loss and found that between 29% and 55% of
respondents believed they experienced long-lasting or permanent memory changes. In
2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left
patients with persistent impairment for memory of public events as compared to RUL
ECT.
Studies have found that patients are often unaware of substantial cognitive deficits
induced by ECT. For example, in June 2008, a Duke University study [ was published
assessing the neuropsychological effects and attitudes in patients after ECT. Forty-six
patients participated in the study, which involved neuropsychological and psychological
testing before and after ECT. The study documented substantial cognitive decline after
ECT on a variety of memory tests, including "verbal memory for word lists and prose
passages and visual memory of geometric designs." The study further found that a
significant number of patients erroneously believed that their memory had improved after
ECT despite the fact that neuropsychological testing clearly showed the opposite. As
stated by the researchers, "Indeed, there was a slight trend towards [patients reporting]
improved memory functioning, despite the objective neuropsychological data indicating
significantly lower recognition and delayed recall." Based on their findings, the authors
issued the following recommendation:

"When ECT is provided to adolescents, the potential impact of such cognitive

changes should be discussed with the patients and their parents or guardians in terms of
implications for not only the patient’s emotional functioning but cognitive functioning as
well, particularly upon his or her academic performance. In summary, we argue that an
individual cost-benefit analysis should be made in light of the implications of the
potential benefits versus costs of ECT upon improving emotional functioning and the
impact that potential memory changes may have on real-world functioning and quality of
life."

Controversy over long-term effects on general cognition

According to prominent ECT researcher Harold Sackeim, "despite over fifty years
of clinical use and ongoing controversy", until 2007 there had "never been a large-scale,
prospective study of the cognitive effects of ECT." In this first-ever large-scale study
(347 subjects), Sackeim and colleagues found that at least some forms (namely bilateral
application and sine wave currents) of ECT "routine[ly]" lead to "adverse cognitive
effects," including global cognitive deficits and memory loss, that persist for at least six
months after treatment, suggesting that the induced deficits may be permanent. The
authors also warned that their findings did not suggest that right-unilateral ECT did not
also lead to chronic cognitive deficits.

Harold Sackeim can be seen in a videotaped deposition briefly discussing the

findings of this study and why, in his opinion, earlier studies had failed to find evidence
of long-term harm from ECT. Despite over fifty years of clinical use, Sackeim states that
prior to 2001, "the field itself never really had an opportunity to have a discussion about
patients who have complaints about long-term memory loss." In this video clip, Sackeim
also reveals that at a California ECT conference with 200 practitioners present, when
polled as to whether they think ECT can lead to chronic cognitive deficits, two-thirds
raised their hands. Sackeim says this was "almost a watershed moment for the field", and
was the "first time publicly that the field itself said 'no' to the position that it can't
happen."
 In July 2007, a second study was published concluding that ECT routinely leads
to chronic, substantial cognitive deficits, and the findings were not limited to any
particular forms of ECT. The study, led by psychiatrist Glenda MacQueen and
colleagues, found that patients treated with ECT for bipolar disorder show marked
deficits across multiple cognitive domains. According to the researchers, "Subjects who
had received remote ECT had further impairment on a variety of learning and memory
tests when compared with patients with no past ECT. This degree of impairment could
not be accounted for by illness state at the time of assessment or by differential past
illness burden between patient groups." Despite the findings of chronic, global cognitive
deficits in post-ECT patients, MacQueen and colleagues suggest that it is "unlikely that
such findings, even if confirmed, would significantly change the risk–benefit ratio of this
notably effective treatment."

Six months after the publication of the Sackeim study documenting routine, long-
term memory loss after ECT, prominent ECT researcher Max Fink published a review in
the journal Psychosomatics concluding that patient complaints of memory loss after ECT
are "rare" and should be "characterized as somatoform disorders, rather than as evidence
of brain damage, thus warranting psychological treatment for such disorders." Based on
his findings, Fink suggests that, "Instead of endorsing these reports as the direct
consequence of ECT, especially in patients who have recovered from their depressive
illness, lost their suicidal drive, and have improved social functioning, is it not more
useful to accept the complaint as a somatoform disorder, explore the basis in the
individual’s history and experience, and offer appropriate supportive treatment?"

Most recent reviews of the literature and other articles continue to characterize
ECT as safe and effective. For example, in June 2009, Portuguese researchers published a
review on the safety and efficacy of ECT in an article entitled, Electroconvulsive
Therapy: Myths and Evidences. In their review, the researchers conclude that ECT is an
"efficient, safe and even life saving treatment for several psychiatric disorders." In 2008,
Yale researchers published a review on the safety and efficacy of ECT in elderly patients.
According to the authors, "ECT is well established as a safe and effective treatment for
several psychiatric disorders." And in a June 2009 article published in the Journal of
ECT, Iranian researchers observe that, "Despite the wide consensus over the safety and
efficacy of electroconvulsive therapy (ECT), it still faces negative publicity and
unfavorable attitudes of patients and families."

Psychiatrist Peter Breggin, chief editor of the journal Ethical Human Psychology
and Psychiatry, is a leading critic of ECT who believes the procedure is neither safe nor
effective. In a published article reviewing the findings of Harold Sackeim's 2007 study on
the cognitive effects of ECT, Breggin accuses Max Fink and other pro-ECT researchers
of having a history of "systematically covering up damage done to millions of [ECT]
patients throughout the world." He disagrees with the position that findings of chronic,
global cognitive deficits should have no bearing on the risk-benefit ratio of ECT, and he
believes it's important to address the "actual impact of these losses on the lives of
individual patients." In a section of his paper entitled Destroying Lives, Dr. Breggin
writes, "Even when these injured people can continue to function on a superficial social
basis, they nonetheless suffer devastation of their identities due to the obliteration of key
aspects of their personal lives. The loss of the ability to retain and learn new material is
not only humiliating and depressing but also disabling. Even when relatively subtle, these
activities can disrupt routine activities of living."

A study published in 2004 in the Journal of Mental Health reported that 35 to

42% of patients said ECT resulted in loss of intelligence. The study also reported, "There
is no overlap between clinical and consumer studies on the question of benefit."

A recent article by a neuropsychologist and a psychiatrist in Dublin suggests that

ECT patients who experience cognitive problems following ECT should be offered some
form of cognitive rehabilitation. The authors say that the failure to attempt to rehabilitate
patients may be partly responsible for the negative public image of ECT.

Effects on brain structure

Considerable controversy exists over the effects of ECT on brain tissue despite
the fact that a number of mental health associations, including the American Psychiatric
Association, have concluded that there is no evidence that ECT causes structural brain
damage. A 1999 report by the United States Surgeon General states, "The fears that ECT
causes gross structural brain pathology have not been supported by decades of
methodologically sound research in both humans and animals". However, not all experts
agree that ECT does not cause brain damage, and two studies have been published since
2007 finding that at least some forms of ECT may result in widespread, persisting,
generalized cognitive dysfunction, which would seem to support claims that ECT causes
brain damage.

A leading critic of ECT, psychiatrist Peter Breggin has published books and
reviews of the literature purporting to show that ECT routinely causes brain damage as
evidenced by a considerable list of studies in humans and animals. In particular, Dr.
Breggin asserts that animal and human autopsy studies have shown that ECT routinely
causes ‘widespread pinpoint hemorrhages and scattered cell death.’ According to Dr.
Breggin, the 1990 APA task force report on ECT ignored much of the scientific literature
pointing out the negative effects of electroshock therapy. For example, in 1952 Hans
Hartelius conducted and published an animal study on cats entitled Cerebral Changes
Following Electrically Induced Convulsions in which a double-blind microscopic
pathology examination showed that it was possible to distinguish the 8 shocked animals
from the 8 non-shocked animals with remarkable accuracy based on statistically
significant structural changes to the brain, including vessel wall changes, gliosis, and
nerve cell changes. Based on the detection of shadow cells and neuronophagia, Hartelius
determined that there was irreversible damage to neurons associated with electroshock.

Proponents argue that the addition of hyper oxygenation and refinement in

technique in the last thirty years has made ECT safe, and a majority of published reviews
in recent decades have reflected this position. In a 2004 study designed to evaluate
whether modern ECT techniques lead to identifiable brain damage, twelve monkeys
underwent daily electroshock for six weeks under conditions meant to simulate human
ECT; the animals were then sacrificed and their brains were compared to monkeys
undergoing anesthesia alone. According to the researchers, "None of the ECT-treated
monkeys showed pathological findings."

There are recent animal studies that have documented significant brain damage
after an electroshock series. For example, in 2005, Russian researchers published a study
entitled, Electroconvulsive Shock Induces Neuron Death in the Mouse Hippocampus:
Correlation of Neurodegeneration with Convulsive Activity. In this study, the researchers
found that after an electroshock series, there was a significant loss of neurons in parts of
the brain and particularly in defined parts of the hippocampus where up to 10% of
neurons were killed. The researchers conclude that "the main cause of neuron death is
convulsions evoked by electric shocks." In 2008, Portuguese researchers conducted a rat
study aimed at answering the question of whether an electroshock series causes structural
changes in vulnerable parts of the brain. According to the authors, "This study answers
positively the question of whether repeated administration of ECS seizures can cause
brain lesions. Our data are consistent with findings from other animal models and from
human studies in showing that neurons located in the entorhinal cortex and in the hilus of
the dentate gyrus are particularly vulnerable to repeated seizures."

Many expert proponents of ECT maintain that the procedure is safe and does not
cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief
editor of the Journal of ECT states in a recent published interview that, "There are a
number of well-designed studies that show ECT does not cause brain damage and
numerous reports of patients who have received a large number of treatments over their
lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites
specifically to a study purporting to show an absence of cognitive impairment in eight
subjects after more than 100 lifetime ECT treatments. One of the authors of the cited
study, Harold Sackeim, published a large-scale study less than a month after this
interview concluding that the type of ECT used in the eight patients receiving the 100
lifetime treatments, bilateral sine wave, routinely leads to persistent, global cognitive
deficits (discussed supra). Dr. Kellner states that, "Rather than cause brain damage, there
is evidence that ECT may reverse some of the damaging effects of serious psychiatric
illness."

Effects in pregnancy

If steps are taken to decrease potential risks, ECT is generally accepted to be

relatively safe during all trimesters of pregnancy, particularly when compared to
pharmacological treatments. Suggested preparation for ECT during pregnancy includes a
pelvic examination, discontinuation of nonessential ant cholinergic medication, uterine
tocodynamometry, intravenous hydration, and administration of a no particulate antacid.
During ECT, elevation of the pregnant woman's right hip, external fetal cardiac
monitoring, intubation, and avoidance of excessive hyperventilation are recommended.
Much of the medical literature in this area is composed of case studies of single or twin
pregnancies, and although some have reported serious complications, the majority have
found ECT to be safe.

Administration

Informed consent is sought before treatment. Patients are informed about the risks
and benefits of the procedure. Patients are also made aware of risks and benefits of other
treatments and of not having the procedure done at all. Depending on the jurisdiction the
need for further inputs from other medical professionals or legal professionals may be
required. ECT is usually given on an in-patient basis. Prior to treatment a patient is given
a short-acting anesthetic such as methohexital, propofol, etomidate, or thiopental, a
muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to
inhibit salivation.

Both electrodes can be placed one on the same side of the patient's head. This is
known as unilateral ECT. Unilateral ECT is used first to minimize side effects (memory
loss). When electrodes are placed on both sides of the head, this is known as bilateral
ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere
between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects
than bilateral but is considered less effective. In the USA most patients receive bilateral
ECT. In the UK almost all patients receive bilateral ECT.

The electrodes deliver an electrical stimulus. The stimulus levels recommended

for ECT are in excess of an individual's seizure threshold: about one and a half times
seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. Below these
levels treatment may not be effective in spite of a seizure, while doses massively above
threshold level, especially with bilateral ECT, expose patients to the risk of more severe
cognitive impairment without additional therapeutic gains. Seizure threshold is
determined by trial and error ("dose titration"). Some psychiatrists use dose titration,
some still use "fixed dose" (that is, all patients are given the same dose) and others
compromise by roughly estimating a patient's threshold according to age and sex. Older
men tend to have higher thresholds than younger women, but it is not a hard and fast rule,
and other factors, for example drugs, affect seizure threshold.

ECT machines

Most modern ECT machines deliver a brief-pulse current, which is thought to

cause fewer cognitive effects than the sine-wave currents which were originally used in
ECT.[9] A small minority of psychiatrists in the USA still use sine-wave stimuli. [60] Sine-
wave is no longer used in the UK. [61] Typically, the electrical stimulus used in ECT is
about 800 milliamps and has up to several hundred watts, and the current flows for
between one and 6 seconds.[62] In the USA, ECT machines are manufactured by two
companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad
Swartz, and Mecta. The Food and Drug Administration has classified the devices used to
administer ECT as Class III medical devices.[63] Class III is the highest-risk class of
medical devices. In the UK, the market for ECT machines was long monopolized by
Ectron Ltd, although in recent years some hospitals have started using American
machines. Ectron Ltd was set up by psychiatrist Robert Russell, who together with a
colleague from the Three Counties Asylum, Bedfordshire, invented the Page–Russell
technique of intensive ECT.

Variations in international practice

There is wide variation in ECT use between different countries, different

hospitals, and different psychiatrists. International practice varies considerably from
widespread use of the therapy in many western countries to a small minority of countries
that do not use ECT at all, such as Slovenia. Guidelines on the use of ECT are stringent in
the USA and the UK. Modern standards are not always followed throughout the world
and not all countries that use ECT have written technical standards. The use of both
anesthesia and muscle relaxants is universally recommended in the administration of
ECT. If anesthesia and muscle relaxants are not used the procedure is called unmodified
ECT. In a minority of countries such as Japan, India, [and Nigeria, ECT may be used
without anesthesia. WHO has called for a worldwide ban on unmodified ECT and the
topic is currently being debated in countries like India. The practice has been recently
abolished in Turkey's largest psychiatric hospital. A major difficulty for developing
countries in eliminating unmodified ECT is a lack of trained anesthesiologists available
to administer the procedure. A small minority of countries never seek consent before
administering ECT. This significantly uneven application of ECT around the world
continues to make ECT a controversial procedure.

Sarah Hall reports, "ECT has been dogged by conflict between psychiatrists who
swear by it, and some patients and families of patients who say that their lives have been
ruined by it. It is controversial in some European countries such as the Netherlands and
Italy, where its use is severely restricted".

Mechanism of action

The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the
person loses consciousness and has convulsions) lasting for at least 15 seconds. Although
a large amount of research has been carried out, the exact mechanism of action of ECT
remains elusive. The main reasons for this are the difficulty of isolating the therapeutic
effect from the plethora of effects that accompany the anesthetic, electric shock and
seizure; the differences between the brains of humans and those of other animals; and the
lack of satisfactory animal models of mental illness.

Electroconvulsive Therapy (ECT) increases serum brain-derived neurotrophic factor

(BDNF) in drug resistant depressed patients.

Legal status

Informed consent
It is widely acknowledged internationally that obtaining the written, informed consent of
the patient is important before ECT is administered. The World Health Organization, in
its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental
Health," specifically states, "ECT should be administered only after obtaining informed
consent."[84]

In the US, this doctrine places a legal obligation on a doctor to make a patient aware of:
the reason for treatment, the risks and benefits of a proposed treatment, the risks and
benefits of alternative treatment, and the risks and benefits of receiving no treatment. The
patient is then given the opportunity to accept or reject the treatment. The form states
how many treatments are recommended and also makes the patient aware that the
treatment may be revoked at anytime during a course of ECT. The Surgeon General's
Report on Mental Health states that patients should be warned that the benefits of ECT
are short-lived without active continuation treatment in the form of drugs or further ECT,
and that there may be some risk of permanent, severe memory loss after ECT. The report
advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or
videos, both before and during a course of ECT.

To demonstrate what he believes should be required to fully satisfy the legal obligation
for informed consent, one psychiatrist, working for an anti-psychiatry organization, has
formulated his own consent form[85] using the consent form developed and enacted by the
Texas Legislature as a model.[86]

In the UK, in order for consent to be valid it requires an explanation in "broad terms" of
the nature of the procedure and its likely effects. [87] One review from 2005 found that
only about half of patients felt they were given sufficient information about ECT and its
adverse effects,[88] and another survey found that about fifty percent of psychiatrists and
nurses agreed with them.[89]

A 2005 study published in the British Journal of Psychiatry described patients'

perspectives on the adequacy of informed consent before ECT. The study found that,
"About half (45–55%) of patients reported they were given an adequate explanation of
ECT, implying a similar percentage felt they were not." The authors also stated:

"Approximately a third did not feel they had freely consented to ECT even when they had
signed a consent form. The proportion who feels they did not freely choose the treatment
has actually increased over time. The same themes arise whether the patient had received
treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients
are sufficient to ensure informed consent with respect to ECT, at least in England and
Wales."

Involuntary ECT

Procedures for involuntary ECT vary from country to country depending on local mental
health laws. Legal proceedings are required in some countries, while in others ECT is
seen as another form of treatment that may be given involuntarily as long as legal
conditions are observed.

In most states in the USA, a judicial order following a formal hearing is needed
before a patient can be forced to undergo involuntary ECT. Patients may be represented
by legal counsel at the hearing. Oregon Revised Statutes allow for involuntary ECT with
the signature of a physician independent of the patient's facility, and no judicial order or
legal counsel are required. According to the Surgeon General's Report on Mental Health,
"As a rule, the law requires that such petitions are granted only where the prompt
institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave
danger because of lack of food or fluid intake caused by catatonia." However, there are
legal loopholes that thwart strict adherence to this principle. For example, an American
citizen was being forced to undergo ECT against his will in 2009, even though his life
was not in danger. In this March 17, 2009 video, the man, his mother, and advocates,
speak out against his forced ECT. The description of the video states that "Though
Sandford, 54, is not charged with any crime, he has received over 40 such rounds of
shocks on an outpatient basis so far – even after his original mental problems have long
since subsided and he has repeatedly asked for the shocks to stop. Over the objections of
Sandford, his mother and friends, his legal conservator at Lutheran Social Service of MN
(LSSMN) has gone to court and succeeded in mandating a continuation of the
procedure." Twin Cities Indymedia asserts "Like all other USA states, Minnesota has
[legal] loopholes allowing [its] citizens to receive electroshock over their expressed
wishes."

Until 2009 in England and Wales, the Mental Health Act 1983 allowed the use of
ECT on detained patients whether or not they had capacity to consent to it, so long as the
treatment was likely to alleviate or prevent deterioration in a condition and was
authorized by a psychiatrist from the Mental Health Act Commission's panel. However,
following amendments which took effect in 2009, ECT may not be given to a patient who
has capacity to refuse to consent to it, irrespective of his or her detention under the Act,
although treatment may still be given to capacitous patients in an emergency under
Section 62 of the Act. If the treating psychiatrist thinks the need for treatment is urgent
they may start a course of ECT before authorization. About 2,000 people a year in
England and Wales are treated without their consent under the Mental Health Act, with a
small number of informal patients treated in this way under common law. In Scotland the
Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the
right to refuse ECT.

Duress in involuntary ECT makes reports about its effects, by patients while
under duress, uncertain in their validity.

Involuntary electroshock contravenes the principle of autonomy in medical ethics.

The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will
of the patient is supreme. It implies that a patient has the right to refuse a medical
treatment, such as ECT.
Patient experience

The APA ECT taskforce guidelines report findings that most patients find ECT no
worse than going to the dentist, and many found it less stressful than the dentist. They
report that other research finds that most patients would voluntarily receive ECT again if
needed.

NICE ECT guidelines report that some individuals consider ECT to have been a
beneficial and lifesaving treatment, while others reported feelings of terror, shame and
distress, and found it positively harmful and an abusive invasion of personal autonomy,
especially when administered without their consent.

Individual positive depictions

Kitty Dukakis, wife of politician Michael Dukakis, reports in a Newsweek article

mostly positive effects from electroconvulsive therapy, and regards memory loss as an
acceptable price to pay for relief from depression.

For me, the memory issues are real but manageable. Things I lose generally come
back. Other memories I prefer to lose, including those about the depression I was
suffering. But there are some memories—of meetings I have attended, people's homes I
have visited—that I don't want to lose but I can't help it. They generally involve things I
did two weeks before and two weeks after ECT. Often they are just wiped out....I have
learned ways to partly compensate for whatever loss I still experience. I call my sister
Jinny, Michael and my kids, asking what my niece Betsy's phone number is, what we did
yesterday and what we are planning to do tomorrow. I apologize prior to asking. I wonder
when they are going to run out of patience with "Kitty being Kitty." I hate losing
memories, which means losing control over my past and my mind, but the control ECT
gives me over my disabling depression is worth this relatively minor cost. It just is.

American psychotherapist Martha Manning's autobiographical

Undercurrentsacknowledges the downside of treatment: "I felt like I'd been hit by a truck
for a while, but that was, comparatively speaking, not so bad," as well as the upside:
"Afterwards, I thought, do regular people feel this way all the time? It's like you've not
been in on a great joke for the whole of your life."

In his autobiographical book Electroboy, American writer Andy Behrman

describes undergoing ECT as a treatment for bipolar disorder while under house-arrest: "I
wake up thirty minutes later and think I am in a hotel in Acapulco. My head feels as if I
have just downed a frozen margarita too quickly. My jaws and limbs ache. But I am
elated."

Curtis Hartmann, a lawyer in western Massachusetts, stated: "ECT, a treatment of

last resort for severe, debilitating depression, is all that has ever worked for me. I awaken
about 20 minutes later, and although I am still groggy with anesthesia, much of the
hellish depression is gone. It is a disease that for me, literally steals me from myself—a
disease that executes me and then forces me to stand and look down at my corpse.
Thankfully, ECT has kept my monster at bay, my hope intact".

Individual negative depictions

Negative effects of ECT have been reported by noteworthy individuals.

Ernest Hemingway, American author, committed suicide shortly after ECT at the
Menninger Clinic in 1961. He is reported to have said to his biographer, "Well, what is
the sense of ruining my head and erasing my memory, which is my capital, and putting
me out of business? It was a brilliant cure but we lost the patient...."

In 2005, "Peggy S. Salters, 60, sued Palmetto Baptist Medical Center in

Columbia, as well as the three doctors responsible for her care. As the result of an
intensive course of outpatient ECT in 2000, she lost all memories of the past 30 years of
her life, including all memories of her husband of three decades, now deceased, and the
births of her three children. Ms. Salters held a Masters of Science in nursing and had a
long career as a psychiatric nurse, but lost her knowledge of nursing skills and was
unable to return to work after ECT." The jury awarded Salters $635,177 in compensation
for her inability to work. The judgment was upheld upon appeal.

Registered nurse Barbara C. Cody reports in a letter to the Washington Post that
her life was forever changed by 13 outpatient ECTs she received in 1983. "Shock
'therapy' totally and permanently disabled me. EEGs [electroencephalograms] verify the
extensive damage shock did to my brain. Fifteen to 20 years of my life were simply
erased; only small bits and pieces have returned. I was also left with short-term memory
impairment and serious cognitive deficits. [deletion] Shock 'therapy' took my past, my
college education, my musical abilities, even the knowledge that my children were, in
fact, my children. I call ECT a rape of the soul."

In 2007, a judge canceled a two year old court order that allowed the involuntary
electroshock of Simone D., a psychiatric patient at Creedmoor Psychiatric Center in the
state of New York. Although Simone spoke only Spanish, she rarely received access to
staff fluent in her language. Simone previously had 200 electroshocks. However, she
communicated that she did not want more electroshock. Simone stated, "Electroshock
causes more pain. I suffer more from shock treatment! "

In 2008, David Tarloff, a psychiatric patient who had received electroshock,

assaulted two therapists in the city of New York. Tarloff injured one therapist and killed
the other. One of the therapists was Kent Shinbach, a psychiatrist who had an interest in
electroconvulsive therapy. "It is not clear whether Dr. Shinbach played any role in Mr.
Tarloff's shock therapy". However, Tarloff told investigators that Shinbach had given
Tarloff psychiatric treatment at a psychiatric facility initially in 1991.

In an interview with Houston Chronicle in 1996, Melissa Holliday, a former extra

on Baywatch and model for Playboy stated the ECT she received in 1995, "ruined her
life." She went on to state, "I've been through a rape, and electroshock therapy is worse.
If you haven't gone through it, I can't explain it."

Liz Spikol, the senior contributing editor of Philadelphia Weekly, wrote of her
ECT in 1996, "Not only was the ECT ineffective, it was incredibly damaging to my
cognitive functioning and memory. But sometimes it's hard to be sure of yourself when
everyone "credible"—scientists, ECT docs, researchers—are telling you that your reality
isn't real. How many times have I been told my memory loss wasn't due to ECT but to
depression? How many times have I been told that, like a lot of other consumers, I must
be perceiving this incorrectly? How many times have people told me that my feelings of
trauma related to the ECT are misplaced and unusual? It's as if I was raped and people
kept telling me not to be upset—that it wasn't that bad."

Public perception and mass media

A questionnaire survey of 379 members of the general public in Australia

indicated that more than 60% of respondents had some knowledge about the main aspects
of ECT. Participants were generally opposed to the use of ECT on depressed individuals
with psychosocial issues, on children, and on involuntary patients. Public perceptions of
ECT were found to be mainly negative.

Nursing Care

There are four components of nursing care in ECT: (1) providing emotional and
educational support to the patient and family/career; (2) assessing the pre-treatment plan
and the patient’s behavior, memory, and functional ability prior to ECT; (3) preparing
and monitoring the patient during the actual procedure; and (4) recovering patient,
observing and interpreting patient responses to ECT with recommendations for changes
in the treatment plan as appropriate. These elements of nursing care should be reflected in
the nursing care plan for patients receiving ECT.

Providing Educational And Emotional Support

Nursing care starts as soon as the patient and family / career are offered ECT as a
possible treatment option. At first, a vital role of the nurse will be to give the patient and
family / carer an opportunity to express their feelings, including any myths or
misconceptions about ECT. Patients may describe fear of pain, dying from electrocution,
suffering permanent memory loss, or experiencing impaired intellectual functioning. As
the patient expresses these fears and concerns, the nurse can clarify misconceptions and
emphasise the therapeutic value of the procedure. These first interactions allow for the
building of trust and rapport necessary to maintain a therapeutic nurse-patient
relationship. Supporting the patient and family / career in their need to discuss, question,
and explore their feelings and concerns about ECT should be an essential part of nursing
care before, during and after treatment.
 Continuing on from this initial meeting the nurse can begin “ECT teaching”.
Depending on the patient’s presenting mental state, this should allow for the patient’s
anxiety, readiness to learn, and ability to comprehend.
Where ever possible, family / career teaching should take place at the same time
as patient teaching, and the amount of information given should be individualized for
each patient and family / career. The nurse should review the information the patient and
family / career have received from the doctor regarding the procedure, and try to answer
any questions the patient and family / career might have about this information. During
this assessment process, the nurse should also try to find out what specific patient
behaviors the family / career associates with the patient’s illness, and ascertain whether
the patient or a family member has had ECT in the past. Any information about the
family’s previous experience with ECT will help the nurse identify familial beliefs about
the patient’s illness, the ECT treatment, and the expected prognosis. Patient and family /
career should also be asked what other exposure they may have had to ECT, such as
through friends who have received it, or by reading about it, or by seeing it portrayed in a
film such as One flew over the cuckoos nest. Open – ended questions can give the nurse
the opportunity to identify and correct misinformation and deal with specific concerns the
patient or family / career may have about the procedure. E.g. What concerns do you have
about receiving the anesthetic? How do you think you will feel after the first treatment?
What do you know about ECT? These nursing actions may then promote the family’s
ability to provide support to the patient during the treatment and so further allay the
patient’s anxiety.

An information booklet and video presentation may be used to supplement

teaching the patient and family / career about ECT. A tour of the treatment suite itself
may help familiarize the patient with the area, procedure, and equipment. Encouraging
the patient to talk with another patient who has benefited from ECT may be an additional
source of information.

The nurse should facilitate flexibility in family / career visiting arrangements,

particularly during the patient’s first few treatments, allowing for family visitation before
and after ECT if the patient and family / career desire. This allays the family’s anxieties
and concerns about the patient’s treatment, while encouraging the family / career to
provide support for the patient. The nurse should also encourage the family / career to
visit the patient frequently throughout the course of treatment. The nurse should ascertain
the changes family members observe in the patient and answer questions that arise. In
some instances the patient may request that a member of their family or career be present
in the treatment room whilst they receive ECT. They should discuss this with their
doctor. The appointed family member / career should be assessed and prepared, using
such resources as a training video which shows someone having ECT. The multi
disciplinary team must be informed of the pending presence of the family member /
career in the treatment room.
Informed Consent For ECT

In November 2001 the DOH published the Good practice in consent

implementation guide : consent to examination or treatment.

Before beginning ECT, an informed consent should be signed by the patient. In

England and Wales, if the patient does not have the capacity to consent, a form for
section 58 of the Mental Health Act must be completed by a second opinion approved
doctor, or in an emergency and with a view to a section 58 being arranged a form for a
section 62 of the Mental Health Act can be completed by the Responsible Medical
Officer. The patient should be provided with Mental Health Act leaflet 3 in these cases.
The consent acknowledges the patient’s rights to obtain or refuse treatment. The consent
form must comply with the recent Department of Health guidelines on consent
documentation. Even though it is the doctor’s ultimate responsibility to provide an
explanation of the procedure when obtaining consent, the nurse plays an integral role in
the consent process.

Informed consent is a dynamic process that is not completed with the signing of a
formal document, but it implies a process that continues throughout the course of
treatment. It suggests a number of nursing activities. It is helpful if a nurse is present at
the time when the information for consent is presented to the patient. The most
appropriate nurse is one who has established a trusting and therapeutic relationship with
the patient and who is best able to assess whether the patient comprehends the
explanation. The presence of a nurse at this time may facilitate the patient’s confidence in
asking questions, and the nurse may be able to simplify the language if necessary. The
nurse can also ensure that the patient has been provided with a full explanation;
understands the nature, purpose, and implications of the treatment, including the option to
withdraw consent at any time; and has had all his or her questions answered before
signing the consent form. After signing the informed consent, but prior to beginning
treatment, the nurse should again thoroughly review this information. The nurse should
discuss the treatment in an open and direct manner, so communicating that ECT is an
accepted and beneficial form of treatment.

It is the responsibility of the psychiatrist to obtain the patient’s consent.

Depressed patients frequently experience impaired concentration and so are less likely to
comprehend and retain new information. For these patients, it is essential that the nurse
repeat the information given by the psychiatrist at regular intervals, because new
knowledge is seldom fully absorbed after only one explanation. Throughout the patient’s
treatment course, the nurse should reinforce what the patient already understands, (note,
the level of understanding varies from patient to patient, and some patients may never
understand the information given to them). Where applicable, the nurse should remind
the patient of anything he or she has forgotten, and provide the patient with the
opportunity to ask new questions. Written information also available in other languages
should be provided to the patient and their family / career. An interpreter should be
arranged if required. The patient should be informed about how to obtain additional
information and access to an independent advocate.
Pretreatment Nursing Care

The ECT treatment nurse should ensure that the treatment suite is properly
prepared for the ECT procedure. The equipment needed to provide optimal ECT patient
care, as recommended by the Royal College of Psychiatrists is stipulated in their ECTAS
standards. An adjustable height stretcher trolley should be available for the less ambulant
patients. Other moving and handling aids should also be accessible.

In order to provide best practice nursing care for the ECT patient, a pre-treatment
checklist should be completed as designated by local hospital policy. Arrangements
should be made for the safekeeping of the patient’s valuables. The ECT nurse should
check that all relevant documentation has been completed. The nurse should explain the
procedure to the patient again and ask whether they have any more questions or queries,
providing reassurance.

Because general anesthesia is required for ECT, the patient should fast from food
and fluids, ( as per local policy) before treatment to prevent possible aspiration. The
exceptions could be the patients who are taking cardiac medications, anti hypertensive, or
H2 blockers routinely. These medications should be administered before treatment as
directed by the doctor, with a sip of water. Day patients should avoid a heavy meal the
evening before the treatment. On the morning of treatment the patient should be asked to
remove make up, nail varnish, body piercing etc. The nurse should ask the patient when
he or she last ate and last drank. The patient’s hair should be clean and dry to allow for
electrode contact. Hairpins, hairnets and other hair ornaments should also be removed for
the same reason. The patient should be encouraged to pass urine before the treatment to
avoid incontinence during the procedure and to minimize the likelihood of bladder
distension and damage during treatment. Prostheses, dentures, glasses, hearing aids,
contact lenses, should be removed at the latest possible moment, prior to the
administration of the anesthetic, to prevent problems of communication with the patient.
The patient’s identity is checked and the patient wears an identity bracelet. A protocol for
day / out patients should be in place which covers their needs, inclusive of : preparing
them for leaving hospital after treatment, and a written / verbal contract that they will not
drive and have a responsible adult to care for them for 24 hours after treatment,
arrangements for further appointments.

The patient must be escorted to the ECT clinic waiting area, through ECT and
recovery and back to the ward by a qualified nurse or equivalent. (9) In the case of in-
patients, the ideal escort is the patient’s Named Nurse, while in the case of out-patients,
the patient’s community nurse, key-worker, a member of the ECT team or out-patient
department team should perform a similar function. The escort should be known to the
patient and be aware of the patient’s legal and consent status and have an understanding
of ECT. To further minimise anxiety the escort nurse should consider the use of anxiety
management techniques, ensuring as short a wait as possible in the treatment waiting
room, offering reassurance and support. The doctor may prescribe a pre-med as per local
protocol.
 Special arrangements should be made when patients are given ECT in a clinic
remote from a hospital base, i.e. the patient should have an individual trained nurse
escort, and commuting patients should be treated at the beginning of the session to allow
maximum time for recovery. Regarding anesthesia outside hospital, the view of the
Association of Anesthetists is that the standards of monitoring used during general
anaesthesia should be exactly the same in all locations.

Nursing Care During The Procedure

Because there will be several people in the treatment room, including

psychiatrists, the treatment nurse and the anesthesia staff, the patient should be
introduced to each member of the team and given a brief explanation of the member’s
role in the ECT procedure. The patient should then be assisted on to a trolley and asked to
remove his / her prostheses, dentures, glasses etc. Removing the patients shoes will
allow for the clear observation of the patient’s extremities during the treatment.

Once comfortably on the trolley, a member of the anesthetic staff will insert a
cannulae, while the treatment nurse and other members of the team place leads for
various monitors. One member of the team should provide explanation of the procedure
as it occurs. Dual channel EEG monitoring is recommended by the Royal College of
Psychiatrists (RCP). One electrode is placed to the side of the forehead and the other is
behind the ear, on either side. ECG, pulse oximeter and blood pressure monitoring are
also recommended by the RCP. Capnograph is also recommended by the RCP, in the
event of a patient needing to be intubated. A peripheral nerve stimulator and a means of
measuring the patient’s temperature should also be available for use. Some ECT
machines incorporate monitoring equipment for movement when the seizure is induced.
An initial recording of the patient’s blood pressure, pulse and oxygen saturation should
be made at this stage.

The psychiatrist or nurse cleans areas of the patient’s head with alcohol swabs and
/ or gel at the sites of electrode contact as per local protocol. This is to reduce impedance
and improve the contact of the electrodes with the patient’s head. The areas being cleaned
should be either both the temples for bilateral ECT, or the temple on the non-dominant
side of the brain for unilateral ECT. Exact placement of electrodes for unilateral ECT is
dependent on RCP guidelines and local policy. The anesthetic, muscle relaxant and
oxygen are administered. A disposable or autoclavable bite block is inserted into the
patient’s mouth prior to the delivery of the stimulus to prevent tooth, tongue or gum
damage or joint dislocation. One member of the treatment team records the time elapsed
during the seizure. A local stimulus dosing policy should be in use. Local protocols for
missed seizures and termination of prolonged seizures should be adhered to.

If required and in the absence of the psychiatric trainee, the nurse can assist the
treating psychiatrist by pressing the test / treat button on the ECT machine, whilst the
psychiatrist holds the electrodes on the patient’s head. The nurse must have been trained
and deemed competent by the consultant psychiatrist responsible for ECT. A local
protocol, to ensure the psychiatrist is aware of the nurse’s actions at each stage of the
procedure and to check the dose given, should be adhered to. This protocol must have
been approved by the consultant psychiatrist responsible for ECT.

Once the anesthetist is satisfied that the patient is breathing again and
maintaining their own airway or able to do so with assistance, he / she will be transferred
to the recovery area.

Post treatment Nursing Care

The recovery area should be next to the treatment room to allow access for the
anesthetic staff in the event of an emergency. Oxygen should be administered routinely to
the patient. The area must contain, suction, monitoring and emergency equipment as
recommended by the RCP. The nurse should maintain the patient’s airway and monitor /
record vital signs at regular intervals or more frequently if complications arise. The
patient should be observed by a staff member in close proximity until he or she awakens.
The number of staff in the recovery area should exceed the number of unconscious
patients by one. A post-operative checklist prompts nurses to check for the presence or
absence of common or worrying side-effects at regular intervals after treatment. The
patient may not remember having the treatment, and their thinking may be somewhat
concrete. The nurse should provide frequent reassurance and reorientation until the
patient retains the information. When interacting with the patient, brief distinct direction
is best. Note, in some instances the patient may never retain some information. Simple
cognitive testing pre and post treatment should give some indication of any abnormality
as a result of ECT.

The patient may become restless, agitated, aggressive (post-ictal confusion) and /
or disorientated for a short period of time. The nurse should maintain the patient’s safety.
Verbal interaction is usually ineffective. When the episode has resolved the patient
should be reoriented. A small dose of a benzodiazepine may be effective. When the
patient is ready he or she should be escorted to a final stage area for refreshments and rest
until the recovery staff deem him or her fit to return to the ward.

The recovery nurse should pass on information to the ward nurse / escort about
the patient’s condition, medication administered, patient’s behavior, untoward procedures
or treatment response. This information should be recorded in the ECT notes. A lengthy
seizure may cause an increase in time of patient being disorientated or confused. A longer
time for rest and reorientation may be required. Closer observation may be required. The
patient should be assessed on return to the ward regarding level of observation required
and degree of orientation. If the patient complains of a headache, muscle soreness,
analgesia such as paracetemol may be administered. The patient should be encouraged to
rest. Nausea may be treated with an anti-emetic. Ward staff should continue to provide
support, reminders to the patient of the treatment and reorientation to eliminate patient
distress from post treatment amnesia. The cognitive impairments associated with ECT
treatment mostly reflect changes in memory – i.e. temporary anterograde amnesia and
retrograde amnesia. Memory deficits do not seem to be restricted to personal
autobiographical memory. Memory loss may be distressing to the patient. The nurse
should reinforce that the majority of the memory difficulties will pass within several
weeks, with a minimal amount of memory problems lasting up to 6 months.

Staffing

A trained nurse with relevant experience must be present at each stage of the
treatment. ECT should be administered only in a suitably equipped unit by professionals
who have been trained in its delivery and in the anesthetic techniques required for the
administration of ECT. In busy ECT clinics it is advisable to use nursing assistants to
assist the “core team” with low skill tasks. E.g. Assisting with moving a patient, ensuring
the patient receives refreshments post ECT, telephone communication. All nursing staff
working in the ECT team should receive Basic Life Support training (monthly), Moving
and handling training (annual), Mental Health Act competency (annual). Recovery
nursing staff should receive local recovery skills training inclusive of airway
management, aspiration and suction techniques (6 monthly). Their competency in
recovery must have been assessed. All staff should be familiar with ECT policies and
procedures. The same team should work in the clinic every week for the purposes of
continuity. A budget for staff training specific to ECT, should be available. Staff should
be encouraged to keep up to date with best practice and their training needs should be
formally assessed by appraisal. ECT nursing staff should attend appropriate training and
conference events, e.g. regional ECT nurse group meetings, ECT nurse training
conferences and the RCP ECT training course.

The ECT Clinic Nurse Manager (ECT Nurse)

This nurse (minimum grade F RMN or equivalent) is responsible for the

development and implementation of a cohesive ECT service acting as a clinical and
functional lead. Therefore, he / she should have appropriate ECT related knowledge /
experience and have undergone an induction programme covering ECT policies and
procedures, medical equipment safety and clinical management. He / she should have an
up to date job description with clearly defined roles and responsibilities.
He / she should ensure that the patients, equipment and personnel are prepared and
organised for the session. Emergency resus equipment and drugs should be checked
weekly, or as per local policy. The ECT machine output and electrodes should be
checked. The ECT nurse should ensure that the ECT machine functioning and
maintenance is checked and recorded at least every year or according to machine
guidance. A record of ECT administration should be maintained for quality assurance. An
example of good practice in this area is the Scottish ECT Audit Network. Appropriate
induction and on-going training of staff should be maintained, e.g. ECT policies and
procedures, CPR, Moving and Handling, Mental Health Act, Control and Restraint. The
nurse should offer clinical advice to services across the Trust and assist with liaison
between the ECT clinic team and the patient’s own team..

The nurse should have designated sessional time for the clinics, auditing, teaching
student nurses, risk assessments, administration, supervising and research into best
practise in ECT. He / she should support the ECT consultant with the training of junior
doctors. The ECT nurse should be able to spend time with patients and relatives in order
to provide support and information. User / carer support groups related to ECT should be
supported by the ECT nurse. He / she should receive regular supervision and maintain a
personal development plan related to ECT. He / she should attend specific ECT training
sessions, e.g. Royal College Psychiatrists Training Days, and / or become actively
involved in their regional ECT Nurse Group. The nurse should have protected time to
carry out all of the above duties and should not be expected to be covering a ward or
other responsibilities on the days of treatment. There should be a nominated trained
deputy to cover the absence of the ECT nurse.

Conclusion

Electroconvulsive Therapy has received some bad press as a result of what the
treatment used to be. Yet "ECT has a higher success rate for severe depression than any
other form of treatment." It has also been shown to be an effective form of treatment for
schizophrenia accompanied by catatonia, extreme depression, mania, or other affective
components. The following excerpt on its use in depression from Overcoming Depression
by Dr. Demitris Popolos should help shed some light on the issue.

There's been a resurgence of interest in ECT because it has evolved into a safe
option, one that works. But for a public influenced by Ken Kesey's One Flew Over the
Cuckoo's Nest, whose associations with ECT start with the electric chair & move on to
lightning bolts, electric eels & third rails, it makes for queasy conversation. For all of us.
Let's replace a few of the myths with facts.

ECT has a higher success rate or severe depression than any other form of
treatment. It can be life-saving & produce dramatic results. It is particularly useful for
people who suffer from psychotic depressions or intractable mania, people who cannot
take antidepressants due to problems of health or lack of response & pregnant women
who suffer from depression or mania. A patient who is very intent on suicide, & who
would not wait 3 weeks for an antidepressant to work, would be a good candidate for
ECT because it works more rapidly. In fact, suicide attempts are relatively rare after
ECT.
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 AN ASSIGNMENT ON
ELECTRO
CONVULSIVE THERAPY